1. APPROACH TO THE PATIENT WITH BREAST DISCOMFORT IN PRIMARY CARE
Assist.Prof. Arzu Akalın M.D.

3. Many patients present to their physician for benign conditions of the breast that they perceive to be abnormal

4. Common Complaints Pain Breast mass Nipple discharge Hypertrophy
Breast infections

5. provide timely and effective communication.
You must
Differentiate benign from malignant disease,
Reassure patients with benign conditions,
Manage common symptoms and conditions, and
Seek consultation when necessary
The provider must recognize the emotional distress common during this process
and
provide timely and effective communication.

6. Breast Anatomy

7. Breast Anatomy The breast is composed of 15-20 lobes and contains
glandular,
ductal,
fibrous, and
fatty tissue.

8. More lobes are present in the outer quadrants, especially the upper outer quadrants,
Therefore many breast conditions (among them, breast cancer) occur more frequently in these regions

9. Each lobe contains several lobules
Each lobe contains several lobules. Lobules contain ducts that join to form one of the 6-10 major ducts that emerge at the areola.
Six to ten pinhole openings are present on the areola.

10. Axillary tail of breast tissue
An axillary tail of breast tissue extends toward the anterior axillary fold.

11. Breast Development Begins with embrionic development and
continues through postmenopausal and older years

12. Newborns may present with;
Athelia : Absence of nipple(s)
Polythelia: More than two nipples
Ectopic nipple tissue may occur at any point in the embrionic breast line

13. Amastia
Absence of breast tissue
Polymastia
the presence of
more than two
mammary glands or
nipples

14. Artemis
The Goddess of Ephesus

15. Hypertrophied breast tissue caused by stimulation from maternal estrogen and progesterone.
In most cases spontaneous regression occurs.

16. Prepubertal children may develop unilateral or bilateral soft mobile subareolar nodules of uniform consistency that usually resolve spontaneously within a few months
Biopsy should be avoided as it may impair pubertal breast development

18. In girls, glandular proliferation within the breast marks the normal onset of puberty.
The first sign of puberty is breast bud development (= thelarche) (average age 11 years; range 9 to 13.4 years),
The last sign is full breast development
Thelarche is considered “premature” if it occurs earlier than age 8.

19. Premature thelarche without other signs of pubertal development or accelerated growth is usually benign.
No treatment is needed
EXCEPT :
precocious puberty,
estrogen-producing tumors,
ovarian cysts or
exogenous estrogen exposure

20. In Puberty
Gynecomastia (= the proliferation of glandular breast tissue in a male), is common in the middle phases of pubertal development.
This may be attributed to serum estradiol levels rising to adult levels before serum testosterone levels.
More than 90% of affected boys experience regression within 3 years
Association with precocious puberty is also a concerning sign.

21. Adulthood
The normal adult breast may be soft, but it often feels granular, nodular, or lumpy. This uneven texture is normal and may be termed physiologic nodularity. It is often bilateral.
The nodularity may increase premenstrually – a time when breasts often enlarge and become tender or even painful.

22. Normal Breast
Changes in size and texture throughout the menstrual cycle.
During the premenstrual phase acinar cells increase in number and size, the ductal lumens widen, and breast size and turgor increase.
These changes reverse in the postmenstrual phase.
The left mamma is usually slightly larger than the right

23. During Pregnancy
Due to hyperplasia of the glandular tissue and increased vascularity, the breasts enlarge and become nodular by the third month of gestation as the mammary tissue hypertrophies.
The nipples enlarge, darken, and become more erectile
The areola darken, and Montgomery’s glands appear prominent around the nipples

24. During Pregnancy
The venous pattern over the breasts become increasingly visible as pregnancy progresses.
From mid- to late pregnancy a normal thick, yellowish discharge called colostrum may be expressed from the nipple

25. Lactation
Mastitis is a cellulitis of the interlobular connective tissue within the mammary gland.
The clinical spectrum can range
from focal inflammation
to systemic flulike symptoms of fever, chills, and muscle aches.
The affected breast will usually exhibit
a tender, erythematous,
wedge-shaped swelling.

26. Lactation Most cases occur within the first 2 months postpartum.
The infection is bacterial, usually staphylococci;
the breast skin and the infant’s mouth have been proposed as the source

27. Lactation
The key to the management of mastitis is complete emptying of the breast, warm compresses, early antibiotics, and bed rest.
The patient should be advised to continue breastfeeding; stopping breastfeeding would put her at increased risk of abscess formation.

28. Aging
The breasts tend to diminish in size as glandular tissue atrophies and is replaced by fat.
Although the proportion of fat increases, its total amount may also decrease.
The breasts often become flaccid
and pendulous

29. Gynecomastia It is common for men in their 50s
and 60s to experience breast enlargement.
Gynecomastia associated with
pain,
asymmetry,
rapid onset or progression galactorrhea,
and/or erectile dysfunction
requires further workup
Can also occur due to some drugs and some diseases

30. ASSESSMENT OF AN INDIVIDUAL WITH BREAST COMPLAINTS

31. Keypoints History Examination of the Breast Laboratory Evaluation
Diagnostic Tests
Pathologic Findings

32. History Taking DESCRIBE
when and in what setting symptoms first occurred,
any change over time, and
past history of similar symptoms.
relation of symptoms to the menstrual cycle.
include the menstrual and reproductive history (age of menarche and menopause)

33. History Taking parity (age of the first-term pregnancy);
whether currently pregnant;
lactation;
use of hormonal therapy or contraceptives;
rapidity and amount of weight gain after menopause;
whether breast self-examination is performed
any past breast surgery
The patient should also be queried for any family history of breast and ovarian cancers.

34. Examination of the Breast (Inspection & Palpation)
The exam should be performed in a well-lit room and privacy is facilitated by draping parts of the body not being examined.

35. Examination of the Breast
Inspection
Occurs with the patient seated,
Arms at side;
With hands on hips; and
With arms above the head.
Changes in size, shape, symmetry, or texture are noted.

36. Examination of the Breast
Palpation
Is performed with the
patient supine,
arms flexed at a 90-degree angle at the sides.
Palpation includes supraclavicular, infraclavicular, and axillary nodes.
Compression may identify a mass and/or elicit a discharge.
Nipples should be examined for deviation, retraction, skin changes, or discharge.

39. Laboratory Evaluation
Genetic screening is not part of the routine evaluation

40. Diagnostic Tests Imaging Mammography Ultrasonography
Magnetic resonance imaging is utilized in some settings.
Aspiration
Fine-needle aspiration (FNA)
Fine-needle aspiration and biopsy (FNAB)
Triple test: combines physical examination, mammography, and FNAB
Open biopsy

41. Common Complaints
Pain
Mass
Nipple discharge

42. Pain (Mastalgia)
Pain without an associated mass is unlikely to be the presenting symptom of breast cancer,
Mastalgia may be classified as
Cyclical (2/3)
Noncyclical (1/3)
May be acute or chronic.

43. Pain History Must include Palliative or provocative factors
Quality (dull, sharp, burning, heavy,...)
Radiation (arm, axilla,....)
Severity (mild, severe to limit activities)
Location
Laterality (bilateral / unilateral) of pain

44. Pain History Timing with regard to menstrual cycle
Association with oral contraceptive pills, other hormonal contraceptives or hormone replacement use,
RECENT
Birth
Pregnancy
Loss of pregnancy or termination
History of trauma, heavy muscular exertion, should be sought.

45. Pain - Physical Exam Should be used to evaluate for Mass
Nipple discharge
To localize areas of tenderness
To assess for
Lymphadenopathy
Changes in symmetry,
Contour, and overlying skin

46. Benign Breast Masses General Considerations
Benign breast masses will often change with the menstrual cycle, while worrisome masses are persistent throughout.
Greater than 90% of palpable breast masses in women between 20 and 55 are benign.
Masses may be discrete or poorly defined, but differ from the surrounding breast tissue and the corresponding area in the contralateral breast.
Cancer should be excluded in a woman who presents with a solid mass.

47. Benign Breast Masses Breast cysts Fibrocystic breast changes
Fibroadenoma
Ductal papilloma

48. Breast Cyst
1. Benign
2. May be aspirated if large

49. Fibroadenoma
Most common benign breast tumor

50. Fibrocystic Breast Changes
1) 20%+ of premenopausal women
2) Discomfort, cysts
3) Treatment rarely required

51. Intraductal Papilloma
may produce “chocolate” or bloody discharge from nipple

52. Algorithm for palpable breast mass.
CBE clinical breast examination;
FNA fine-needle aspiration

53. Nipple Discharge
Nipple discharge: Secretions from the breast(s) of a woman who is not lactating
Nipple discharge is an extremely common concern in young women
Most isolated complaints of discharge are benign

54. Nipple Discharge Categorized as Physiologic
Pathologic (nonphysiologic).
Physiologic
Pathologic
Nonspontaneous
Spontaneous
Bilateral
Unilateral
Arising from multiple ducts
Arise from a single duct

55. Carcinoma of the breast
Most common malignant tumor among women
1/8 of women will develop breast cancer

57. Progression to Breast Cancer

58. Physical Signs a. Slowly growing, painless mass
b. May demonstrate retracted nipple
c. May be bleeding from nipple
d. May be distorted areola, or breast contour
e. Skin dimpling* in more advanced stages with
retraction of Cooper’s ligaments
*Dimple=Gamze
Note skin dimpling in the 6 o'clock radius

59. f. Attachment of mass
g. Edema of skin
1)with “orange skin” appearance (peau d’orange) due to blocked lymphatics
h. Enlarged axillary or deep cervical lymph nodes

60. Common sites for metastasis
a. Lungs & pleura
b. Skeleton system (skull, vertebral column, pelvis)
c. Liver
Atypical carcinomas
a. Inflammatory carcinoma (hormonal, chemotherapy)
b. Paget’s disease of the breast

61. Breast Cancer Screening Guidelines of ACS* 2012
BSE ages ≥20 monthly or irregular
CBE ages part of periodic examination at least every 3 year
ages ≥40 annually
Mammography begin anuual mammography at age 40
* American Cancer Society

62. End of Lecture
Class dismissed!